EyeCare Refresh Registration Form

Part 1: Physician Contact Info

* Required Fields

Please fill out the fields below to request your own site and you will receive an email shortly with additional instructions.

* Practice Name

* First Name

* Last Name

Title

* Phone Number

* Email

* Confirm Email

Affiliation

Practice Ownership

If you have any questions, please contact
REFRESH® Direct Support at 1-833-246-4393
Mon-Fri 8:00 AM - 7:00 PM CT